A 65-year-old man presents to the chest pain clinic with a 2-month history of exertional chest pain. He has no past medical history of note. On examination his BP is 130/70 mmHg and his heart rate is 65 bpm in sinus rhythm with a 3/6 pansystolic murmur. He has a positive ETT with inferolateral ST segment depression at 5 minutes Bruce protocol. Coronary angiography reveals severe distal left main stem disease, severe mid-LAD disease, severe mid-circumflex disease, and severe distal RCA disease. An echocardiogram shows severe mitral regurgitation with moderate LV systolic dysfunction. CMR confirms viability in all territories.
What should you do next?
This patient has triple vessel disease with objective evidence of ischaemia. This is an indication for CABG. The ESC Guidelines recommend concomitant MVR if the patient has severe MR and LVEF >30% when planned for CABG.
You get a phone call from the heart failure nurse specialist regarding a patient followed up in clinic for titration of medication. He has dilated cardiomyopathy with an EF of 30%. His most recent BP is 110/60 mmHg with heart rate 60 bpm. He is currently on bisoprolol 7.5 mg od and ramipril 5 mg od. His renal function test results have been phoned through to the specialist nurse:
(Baseline before titration of ACE inhibitor: Na 138 mmol/L, K 4.8 mmol/L, urea 8 mmol/L, creatinine 180 µmol/L.)
What would be your advice?
ESC Guidelines suggest that if creatinine is 265–310 µmol/L or K+ >5.5 mmol/L the dose of ACE inhibitor should be halved and blood chemistry should be monitored closely.
A 36-year-old woman with known idiopathic dilated cardiomyopathy (confirmed by TTE and angiography) is reviewed in the heart failure clinic. She is NYHA class III. Her current medication is bisoprolol 10 mg od, ramipril 7.5 mg od, spironolactone 25 mg od, digoxin 62.5 micrograms od, furosemide 40 mg bd. She has CRT-D in situ. Her heart rate is 70 bpm and her BP is 85/40 mmHg. She has mild peripheral oedema and a raised JVP.
What is your next step?
Transplant candidate if endstage heart disease with a life expectancy of 12–18 months, NYHA class III or IV heart failure, refractory to medical therapy including cardiac resynchronization therapy.
. A 57-year-old woman with known heart failure and EF 42% is reviewed in clinic. She is breathless on walking up one flight of stairs or half a mile on the flat. On examination, her BP is 130/90 mmHg and her heart rate is 75 bpm (SR, ECG QRS < 120 ms). Her chest is clear to auscultation. There are no signs of fluid overload.
Her current medication:
Her recent renal function tests are:
She has not previously tolerated an ACE inhibitor or spironolactone because of deteriorating renal function and hyperkalaemia.
What would you do next?
An ACE inhibitor should only be used in patients with adequate renal function (creatinine ≤221 mmol/L or ≤2.5 mg/dL or eGFR ≥30 mL/min/1.73 m2 ) and a normal serum potassium level. Candesartan and epleronone are also contraindicated in view of the renal function. Furosemide is not indicated because of fluid status. Ivabradine requires an EF <35%. H-ISDN is an alternative to ACE inhibitor/ARB when they are not tolerated, or can be considered in patients on maximal therapy and residual NYHA class II–IV symptoms and EF ≥35%.
A 30-year-old man had a cardiac transplant 5 years previously because of dilated cardiomyopathy. He initially did very well post-transplant. However, he has noticed that he is progressively short of breath on exertion. His TTE shows mid and apical anterior hypokinesia.
What is the most likely diagnosis?
The patient most likely has coronary vasculopathy. The incidence of this is 30–40% at 5 years. It progresses slowly, but as the heart is denervated a high clinical suspicion is required.
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